Executive Dysfunction in
Patients with Cerebrovascular
Risk Factors
Laura Grande, Ph.D.
Geriatric Neuropsychology Laboratory,
New England GRECC
VA Boston Healthcare System
Harvard Medical School
August 23, 2006
Neuropsychology:
What is it good for?
Neuropsychology
• Behavioral expression of brain dysfunction
• Neuropsych exam:
– Assists in diagnosis
– Pt care (management & planning)
• Provides insight into level of functioning
• Not only elderly and geriatric pt’s
Neuropsychology and Medicine
• Ability for self-care and independence
• Understanding and remembering
instructions and recommendations
• Managing complex medical regimens
• Remembering and accurately verbalizing
concerns to physician
• Pt safety (driving)
Cognitive Impairment
• Dementia - prototypical
• Two most common forms:
– Vascular dementia (VaD)
– Dementia of the Alzheimer’s type (AD)
• Differ in initial cognitive changes
Domains of Cognition
Learning/
Memory
Executive
Attention
Functions
Visuo-spatial Language
Domains of Cognition
Learning/
Memory
Attention Executive
Functions
Visuo-spatial Language
Cortical Dementia
Alzheimer’s Disease
• Affects every area of behavior
• Learning and memory - problems with new
information, better recall for older memories
• Visuoperceptual - poor copying & constructional
abilities
• Language - speech, comprehension, semantic
problems, naming, empty speech
• Executive functions
• Personality - emotional changes, irritability, lack of
awareness
• Insidious onset, steady decline
Alzheimer’s Disease
Vascular (Multi-Infarct) Dementia
• Learning and memory - problems learning and
remembering new information, relatively better than
AD pts.
• Other cognitive deficits may include
– Language - aphasia
– Motor - apraxia
– Visuospatial - agnosia
– Executive functions - inattention
• Personality - later in course of disease
• Acute onset, step-wise decline
• Similar to subcortical dementias (PD, HD)
Vascular Dementia (VaD)
• VaD may not be a specific single disease.
• VaD associated with neuroanatomical
changes resulting from vascular disease.
• DSM-IV criteria - mandatory memory
impairment.
• Cognitive impairment observed in those at
risk for VaD (Brady et al 1999; Pugh et al in prep).
Bowler, Steenhuis & Hachinski (1999); Schmidtke & Hill (2002)
Memory vs. Executive Function
• ―Memory‖ problems - Elderly
– Most commonly reported cognitive problem
– Pts concerned about Alzheimer’s disease
– Many problems labeled as memory
• Executive dysfunction in those at risk for VaD
– Hypertension (Brady et al 2001), diabetes (Pugh et al 2004)
– Problems detected prior to pt/family report
• Associated with frontal lobe functions.
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TIFF (Un compressed) decompre ssor
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Major Causes of Death in MA - 2001
Heart Dis & Stroke, 42%
Suicides, homicies, 2%
MVA 1%
Accidents, 3%
Kidney Disease, 3%
Liver Disease, 1%
Respiratory Disease, 6%
Pneumonia & Influ., 4%
AD, 3%
Diabetes, 3%
Cancer, 31%
HIV, 1%
American Heart Association. Heart Disease and Stroke Statistics — 2005 Update. Dallas, Tex.: American Heart Association;
Early identification and Screening
• Evaluation occurs after problems are noticed.
• Cognitive testing for all patients?
– Unnecessary, time consuming, expensive
• Screening in the primary care clinics?
– Physicians reported need for screening (Hogervorst et al, 2001)
– Time is biggest obstacle
– Test familiarity
• Could cognitive decline be minimized by early
detection?
Non-Formal Assessment
• Obtain useful information through
observation and discussion
– Pt’s use of language
– Pt’s memory for own personal history, and new
learning
– Pt’s ability to attend and stay on topic
• Naturalistic environment
Clock Drawing Test as a Screener
• Considered measure of executive functioning.
• Good psychometric properties across versions and
scoring procedures.
• Highly correlated with other cognitive measures.
• Quick administration (≈ 2 minutes).
• Useful as a screening tool in the medical setting?
Please read and do the following carefully:
In the blue box on the next page:
Draw a picture of a clock
Put in all the numbers
Set the time to ten after eleven.
Hand this sheet back and go to the next page
Clock Scoring
• Working Memory • Planning & Organization
Subscale Subscale
– Correct square – Appropriate size
– Numbers in correct order
– Resembles clock
– Numbers evenly spaced
– Includes all numbers
– Hands of different length
– Correct time indicated
(in any manner)
• Four WM points • Four PO points
Total Score = WM subscale + PO subscale
Clock-in-a-Box Score = 8
Clock-in-a-Box Score = 6
Clock-in-a-Box Score = 5
Clock-in-a-Box Score = 3
Clock-in-a-Box = 0
CIB Participants
• 191 participants
– 56 Healthy controls (HC)
– 135 Cardiovascular pts
• 31 Geriatric patients
– Referred for evaluation at MGH
Demographic Information
HC CV Geri
Age, M(SD) 65 (8) 66 (9) 78 (9) *
Education, M(SD)* 15 (3) 13 (2)* 14(2)
Sex (n, % male) 26, 46% 97, 72% 17, 55%
Race (n, % Caucasian) 39, 70% 59, 66% 28, 90%
MMSE* 28.2 27.0 --
CIB - Total Score
8
*
6 *
HC
CV
4 Geri
2
0
CIB
* p<.01
CIB - Subscores
4
*
3 *
*
HC
2 CV
Geri
1
0
Working Memory Planning &
Organization
* p<.01
CIB & EF Measures
Trail A Trail B Phonemic Semantic
Fluency Fluency
CIB Total .074 -.257 * .192 * .010
Working Memory .097 -.166 * .065 .026
Planning/Organization .031 .255 * .240* .005
* p<.05
CIB & Memory Measures
Learning Recall Retention Recognition
CIB Total .330* .304 * .130 .160*
Working Memory .249* .249 * .111 .133
Planning/Organization .300* .263 * .107 .138*
* p<.05
Is the CIB a predictor?
• Does CIB predict performance on
standardized cognitive measures?
– Stepwise linear regression
• CIB total, age & education entered into model
Prediction of performance
• Executive Function Measures
– Trail Making A
54.6 + CIB (-2.211) + Educ (-1.39) + Age (.345)
– Trail Making B
199.98 + CIB (-14.75) + Educ (-7) + Age (.237)
– NOT a significant predictor of fluency
• Memory Measures
– Learning
10.64 + Educ (.341) + CIB (.273) + Age (-.137)
– Recall
3.09 + CIB (.279) + Educ (.256) + Age (-.175)
– Retention
54.25 + CIB (.194)
– NOT a significant predictor of recognition
Cycle of Problems
Cardiac Illness
Diabetes
Difficulty managing
own medications
Missing medications
and problems
Not following Dr.’s plan
following Dr.’s plan
Problems with Illnesses not well-controlled
planning & problem
solving
White matter changes
Disrupted frontal lobe messages
Procedures for Registering
and Getting CE credit
• VA people go to https://vaww.ees.aac.va.gov
• Non-VA go to https://www.ees-learning.net
• First-time users will need to ―click for first time users‖;
others should enter username and password
• On ―Librix homepage‖ click on ―Available courses‖ and
enter keyword ―geriatric‖
• Click on ―Geriatric Audioconference Series: Executive
Dysfunction…‖
• Click on ―Sign me in‖ and follow procedures
For Further Information:
• Vascular Dementia and CIB
– Laura Grande, PhD
– lgrande@heartbrain.com
• New England GRECC
– Kathy Horvath, PhD RN
– Kathy.Horvath@med.va.gov
• Geriatric Audioconference Series
– Ken Shay, DDS, MS
– Kenneth.Shay@va.gov
• Evaluation and CE Credit
– http://vaww.sites.lrn.va.gov/vacatalog/cu_detail.asp?id=22502
– Instructions in ―Brochure‖
Upcoming Calls
• Thursday, September 28, 3 pm eastern:
―Sleep disorders in older people‖
(Sepulveda and Madison GRECCs)